Emergency management of shock in children is presented within this presentation.

1. Care of children with shock
Aklilu Endalamaw (MSc in Pediatrics & Child
Health Nursing, Assistant Professor)
Bahir Dar University, Ethiopia
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2. Care of children with shock
• Shock
• Recognize the consequences of shock if left untreated
• Review the different types of shock seen in pediatrics
• Review causes, signs & symptoms and treatment of
different types of shock
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3. Cont…
Objectives
• After completing shock section, students will be able to:
1. Describe the epidemiology of shock
2. Characterize the various causes of shock and recognize
their clinical presentations
3. Discuss the basic pathophysiology of shock
4. Discuss about the treatment of shock
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4. Case scenarios
A. A 9-month-old girl presents to the emergency department(ED) with a 4-day history of
profuse diarrhea and poor oral intake. On physical examination, she appears irritable.
Her respiratory rate(RR) is 70breaths/min, heart rate(HR) is 180beats/min, and blood
pressure(BP) is 80/50 mm Hg. She has cool, mottled extremities, with sluggish capillary
refill and weak peripheral pulses. Is this just a case of dehydration or could this be
shock?
B. A 14-year-old boy presents to the emergency department with a 1-day history of
headache, general malaise, and fevers. On physical examination, he appears confused.
He has a temperature of 39.9°C,HR of 120beats/min, and BP of 85/28 mmHg. His skin
appear splethoric. His extremities are hot, with flash capillary refill and bounding
pulses. Is this the same entity that is affecting the previous patient?
C. A 2-week-old boy presents to the ED with a 1-day history of poor feeding. On physical
examination, he is difficult to arouse. His RR is 80 breaths/min, HR is 220 beats/min, and
BP is undetectable. He appears cyanotic and has cold extremities and a 5-second
capillary refill time. Is this the same entity as seen with the other two patients? How
should you proceed?
A. Hypovolemic
B. Septic
C. Cardiogenic11/22/2020 Aklilu Endalamaw 4

5. Cont…
• Shock is a life-threatening state that occurs when oxygen and
nutrient delivery are insufficient to meet tissue metabolic
demands (Vincent IL, 2003).
• Oxygen delivery(DO2) is determined by cardiac output (CO) and
the arterial content of oxygen (CaO2):
DO2 (mL/min)= CO (L/min) X CaO2 (mL/L)
• Cardiac output is the product of stroke volume (SV) and HR: CO
(L/min)= SV (L) X HR/min
• Stroke volume (SV) is determined by preload, contractility,
afterload, and Lusitropy.
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S.A.McLellan, 2004

6. Cont…
• Preload: the amount of filling of the ventricle at end diastole
• Afterload: the force against which the ventricle must work to
eject blood during systole
• Contractility: the force generated by the ventricle during systole
• Lusitropy: the degree of myocardial relaxation during diastole
• Heart rate variability relies on an intact autonomic nervous
system and a healthy cardiac conduction system.
S.A.McLellan, 2004; J-OC Dunn, 2016
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7. Cont…
• Arterial oxygen content also dictates oxygen delivery and is determined by
hemoglobin (Hgb), oxygen saturation(SaO2),and the partial pressure of
oxygen(PaO2), as follows:
CaO2 (ml/L)= {[Hgb (g/dL)X1.34 (mL O2/g Hgb) X(SaO2/100)] +
(PaO20.003mLO2/mmHg/dL)} X 10dL/L
• For example, for a patient who has an Hgb value of 15g/dL,PaO2 of100torr, CO of
5L/min,and SaO2 of 98%, the DO2 can be calculated as follows: CaO2= {[15 g/dL X
1.34 mL O2/g Hgb X(98/100)] + (100 X 0.003 mL O2/mm Hg/dL)}X 10 dL/L
• CaO2= 200 mL/L
• DO2=5 L/minX200 mL/L=1,000 mL/min
11/22/2020 Aklilu Endalamaw 7S.A.McLellan, 2004; J-OC Dunn, 2016

8. Cont…
• It is important to recognize that oxygen is not distributed
uniformly to the body. Modulation of systemic vascular
resistance(SVR) in different vascular beds is one of the body’s
primary compensatory mechanisms to shunt blood
preferentially to vital organs such as the heart and brain. In
this way, an increase in SVR may maintain a normal blood
pressure even in the face of inadequate oxygen delivery. In
other words, hypotension need not be present for a child to
be in shock.
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9. Cont…
• Shock refers to a dynamic state ranging from early, compensated
shock to irreversible, terminal shock.
• During the earliest stage of shock, vital organ function is maintained
by a number of compensatory mechanisms, and rapid intervention
can reverse the process.
• If unrecognized or undertreated, compensated shock progresses to
decompensated shock. This stage is characterized by ongoing tissue
ischemia and damage at the cellular and subcellular levels.
Inadequate treatment leads to terminal shock, defined as
irreversible organ damage despite additional resuscitation
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10. Classification and Clinical Presentation of shock
Hypovolemic Shock
• Most common type
• Causes: Diarrhea, bleeding, thermal injury, and inappropriate
diuretic use
• Signs and symptoms: tachycardia, tachypnea, and signs of poor
perfusion, including cool extremities, weak peripheral pulses,
sluggish capillary refill, skin tenting, and dry mucous membranes,
Orthostatic hypotension, weak central pulses, poor urine output,
mental status changes, and metabolic acidosis.
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Taghavi S, Askari R 2019

11. Cardiogenic Shock
• Cardiogenic shock refers to failure of the heart as a pump,
resulting in decreased cardiac output.
• Causes: depressed myocardial contractility, arrhythmias, volume
overload, or diastolic dysfunction
• Infants may present with poor feeding or appear less active and
can quickly progress to lethargy.
• Older children may appear fatigued and complain of difficulty
with breathing or chest pain.
• As shock progresses, they may experience syncope or an altered
mental status.
Subramaniam S, Rutman M 2005
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12. Cont…
• Physical examination may reveal tachycardia, tachypnea,
pallor, cool or mottled extremities, or weak distal pulses.
• Signs of heart failure such as gallop rhythm, jugular venous
distension, crackles (rales), and hepatomegaly may develop
as back pressure of blood into the pulmonary and venous
circulations worsens.
• If there is further deterioration to uncompensated shock,
multisystem organ failure may ensue, leading to coma and
death.
Subramaniam S, Rutman M 200511/22/2020 Aklilu Endalamaw 12

13. Cont…
• Cardiogenic shock can usually be distinguished from septic
and hypovolemic shock by increased venous pressure
(cardiogenic shock). If the venous pressure is greatly
increased, cardiac tamponade.
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14. Cont…
Cardiogenic shock in neonate
• Intrapartum asphyxia is associated with a spectrum of cardiac disturbance including
transient tricuspid insufficiency and cardiogenic shock from global hypoxemic
cardiomyopathy. Creatine kinase MB fraction value is frequently increased. Useful
cardioactive medications include digoxin and low-dose dopamine.
• Rapid supraventncular and ventricular tachycardia may both cause cardiogenic shock.
Supraventricular tachycardia responds well to ice bag, cardioactive medications, and
cardioversion. Ventricular tachycardia is often symptomatic of cardiac tumor.
Ventricular fibrillation is characteristic of long QT interval syndrome.
• If structural cardiovascular disease is the cause, the infant may often be improved by
reopening the ductus arteriosus with prostaglandin E1.
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G T Albrecht , 1993

15. Distributive or Neurogenic shock
• It is caused by derangements in vascular tone that lead to end-organ
hypoperfusion.
• This outcome is seen with anaphylaxis, an immunoglobulin E-mediated
hypersensitivity reaction in which mast cells and basophils release histamine, a
potent vasodilator, and there is massive production of other potent
vasodilators, including prostaglandins and leukotrienes.
• Spinal cord trauma and spinal or epidural anesthesia also can cause
widespread vasoplegia due to loss of sympathetic tone. This situation
sometimes is referred to as neurogenic shock. Unlike other forms of shock,
patients who experience neurogenic shock exhibit hypotension without reflex
tachycardia.
• Septic shock in some children presents with vasoplegia.11/22/2020 Aklilu Endalamaw 15
Smith N et al 2020

16. Septic shock
• In the neonatal period, group B streptococci and Gram
negative bacilli are the predominate pathogens; Streptococcus
pneumoniae, Neisseria meningitidis, Staphylococcus aureus,
and group A streptococci are major causes in older children.
• Children who have altered immune function, such as
congenital immuno-deficiencies or asplenia, or those
undergoing chemotherapy are at risk for a wide spectrum of
infections from bacteria, fungi, viruses, and parasites.
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Richard S et al, 2016

17. Cont…
• Systemic inflammatory response syndrome (SIRS), whereby the body
responds to various insults (infection, trauma, thermal injury, acute
respiratory distress syndrome) with overwhelming inflammation
resulting in hypo- or hyperthermia, tachycardia, tachypnea, and either
an elevated or depressed white blood cell count.
• SIRS by an infection, it is sepsis.
• SIRS is associated with organ dysfunction, it is severe sepsis.
• Septic shock in the pediatric population is characterized by sepsis
accompanied by tachycardia and signs of inadequate perfusion.
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18. Cont…
infection
• Cellular or humoral immunity
with reticuloendothelial system
highly
toxic
response
• Proinflamatory cytokines (tumor
necrosis factor, interleukin-1 & -6)
Septic shock
• Other pro-inflammatory
cytokines & mediators of
sepsis
“Cold” shock
“warm” shock11/22/2020 Aklilu Endalamaw 18

19. Cont….
• “Cold” versus “warm” shock refers to the two primary
clinical presentations of septic shock.
• “Cold”shock describes the pattern of signs and symptoms
seen with low cardiac output and high systemic vascular
resistance.
• Clinical picture of “Cold Shock”: tachycardia, mottled skin,
cool extremities with prolonged capillary refill, and
diminished peripheral pulses. Blood pressure may be
normal. Most septic children have this presentation.
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20. Cont…
• In contrast, most adults and some children present in “warm”
shock due to high cardiac out put and low systemic vascular
resistance.
• CF of “warm shock”: tachycardia, plethora, warm extremities
with flash capillary refill, bounding pulses, and a widened
pulse pressure.
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21. Treatments of shock
Treatment regardless of the cause of shock
• Airway: Patients suffering shock may develop acute lung injury (ALI) or
acute respiratory distress syndrome (ARDS).
• ALI and ARDS are marked by increasingly poor oxygenation
(PaO2/FiO2<300 in ALI and PaO2/FiO2 <200 in ARDS) and ventilation,
despite escalating ventilatory support and worsening bilateral
infiltrates on chest radiograph without signs of left-sided heart failure.
• It is important to recognize ALI or ARDS and respond appropriately with
a lung-protective strategy of ventilation.
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I Santhanam et al, 2009

22. Cont…
• Fluid Therapy: for hypovolemic shock
• Fluid resuscitation in infants and children who have
cardiogenic shock should be approached carefully because
these patients may be hypo-,hyper-,oreuvolemic.
• Antibiotics: when sepsis suspected. It can be difficult to
differentiate septic shock from cardiogenic shock in the
neonate, this age group always should be treated with
antibiotics.
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23. Cont…
• Crystalloid Versus Colloid: The 2007 ACCM clinical practice guidelines for
treatment of neonatal and pediatric septic shock recommend either isotonic
crystalloid or 5% albumin for volume resuscitation in the first hour. Beyond
the first hour, the guidelines recommend crystalloid for patients who have
Hgb values greater than 10g/dL(100g/L)andpackedred blood cell transfusion
for those whose Hgb values are less than 10g/dL(100g/L).Inadditionto
restoring circulating volume, packed red blood cells also serve to increase
oxygen-carrying capacity. Fresh frozen plasma administered as an infusion is
recommended for patients who have a prolonged International Normalized
Ratio.
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24. Cont…
• Cardiovascular support: In cases of fluid-refractory shock and cardiogenic
shock.
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25. Key point
• Treat shock regardless of the cause at emergency
situation and treat the underlying cause accordingly.
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26. References
• Vincent JL, De Backer D. Circulatory shock. N Engl J Med 2013; 369:1726.
• S.A.McLellan, T.S. Walsh. Oxygen delivery and haemoglobin. 2004
• J-OC Dunn MB ChB BAO FRCA, MG Mythen MBBS MD FRCA FFICM FCAI (Hon), and
MP Grocott BSc MBBS MD FRCA FRCP FFICM. Physiology of oxygen transport. BJA
Education, 16 (10): 341–348 (2016)
• Sharven Taghavi; Reza Askari. Hypovolemic Shock. Book Shelf. Updated 2019
• G T Albrecht . Cardiogenic Shock in the Neonate. Indian J Pediatr. May-Jun
1993;60(3):381-91.
• Nicholas Smith; Richard A. Lopez; Michael Silberman. Distributive Shock -
StatPearls - NCBI Bookshelf. 2020
• Published online 2016 Jun 30. doi: 10.1038/nrdp.2016.45
• Richard S. Hotchkiss, Lyle L. Moldawer, Steven M. Opal, Konrad Reinhart, Isaiah R.
Turnbull, and Jean-Louis Vincent. Sepsis and septic shock. Nat Rev Dis Primers.
2016 Jun 30; 2: 16045.
• I Santhanam1, S Ranjit, N Kissoon.. Management of Shock in Children in the
Emergency DepartmentMinerva Pediatr. 2009 Feb;61(1):23-37.
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